A Non-Cure for a Non-Malady: “Reparative Therapy”

would like to share with you this piece about Sexual Orientation Change Effort published by two friends of mine: Dr. Omar Fattal, a psychiatrist in New York and Dr. Hossam Mahmoud, a psychiatrist in Chicago. Both are also current board members of the Lebanese Medical Association for Sexual Health. It was published in Mind Matters, a newsletter by the Illinois Psychiatric Society.

“Reparative Therapy,’ a Non-Cure for a Non-Malady.” Mind Matters, Issue 25, October 2013

By: Omar Fattal, MD MPH and Hossam Mahmoud, MD MPH

Introduction:

Reparative therapy” is a term that has called for much attention and controversy in the media and among mental health care professionals and nonprofessionals. It has been a controversial issue and has become a polarizing topic, in which issues of politics, religion, civil rights and mental health intersect.

Reparative therapy, also known as “conversion therapy” is an approach that has been undertaken by some groups and mental health providers as a way to help “cure” homosexuals of the “disease” of homosexuality. In the opinion of such groups and providers homosexuality or homosexual tendencies are considered a malady, an illness, which requires treatment. However, given that there is no substantiated evidence that reparative therapy is effective as a treatment, and to be in accordance with the terms used by scientifically-sound literature on this topic, the authors prefer to use the term “Sexual Orientation Change Efforts” (SOCE).

The last couple of years have been pivotal with regard to changes that have taken place on the issue of SOCE, across different sectors both in the United States and abroad. The following are just some of the changes we have seen in the past two years:

In April 2012, Robert Spitzer, MD, issued an apology directed to the gay community, especially those affected by SOCE, regarding his controversial study (1), which had been misinterpreted as evidence that “highly motivated homosexuals” can change their sexual orientation. (2, 3) Unfortunately, this study has been repeatedly misused as evidence for efficacy of SOCE.

In June 2013, Exodus International, an “ex-gay” organization, whose mission for decades was to help “cure” gay Christians of homosexuality and “help” them turn straight, issued an apology to the gay community (4). It also closed down its “cure ministry.” (5) At this time, it appears that Exodus International has abandoned its attempts of “treat” homosexual tendencies.

SOCE has made headlines over the past few months in different parts of the country. In several states, including California, Massachusetts, New York and New Jersey, bills banning SOCE for minors have either been introduced or passed, with much controversy (6, 7, 8). The bill which passed in California banning SOCE for minors has been appealed on the grounds that it may constitute an “unjustified infringement on free speech.” (6) At the time this article was written, the case was still pending.

On a more global level, SOCE have gained attention worldwide, including in Lebanon. In 2013, three Lebanese health groups spoke out against SOCE. In May, the Lebanese Medical Association for Sexual Health (LebMASH) released a strongly-worded position statement emphasizing that homosexuality is not an illness; furthermore, the statement emphasized that SOCE are not based on sound medical evidence, and that such attempts can be harmful (9). This position statement was followed in July by two announcements from the Lebanese Psychiatric Society (LPS) and Lebanese Psychological Association (LPA) arguing that homosexuality is not an illness and, therefore, does not require treatment. (10) This has been the first time in the Arab World that a professional medical association and a professional psychological association have spoken out against SOCE and asserted that homosexuality is not an illness.

Homosexuality Is Not a Disease:

Before we discuss the ramifications of SOCE, it’s important to examine the “disease” that this “therapy” is claiming it can cure. Homosexuality is not a mental illness.

It has been 40 years since the American Psychiatric Association (APA) removed homosexuality from its list of conditions considered to be mental disorders. As a district branch of the APA, IPS holds the same position with regards to this issue since it was changed in 1973. On a more global scale, in 1990 The World Health Organization (WHO) removed homosexuality from its list of disorders, known as the International Statistical Classification of Diseases and Related Health Problems (ICD) (11) As per the Pan American Health Organization (PAHO) which is the Regional Office of WHO, “In none of its individual manifestations does homosexuality constitute a disorder or an illness and therefore it requires no cure.” (12)

Unfortunately, to this date, some people still criticize the APA’s decision to remove homosexuality from the list of mental illnesses and dismiss this decision as being based on politics and not science. It is true that the APA – like all major associations – has several interest groups within its membership that may influence its policies, and the Association may respond to external lobbying as well.

In the same way that there were groups in the years preceding 1973 asking the APA to remove homosexuality from the list of mental illnesses, there were other groups asking the APA to keep homosexuality on the list of mental illnesses. Simply because a decision was made partially due to pressure from certain groups does not mean that the decision itself was not a valid or that the APA did not incorporate scientifically sound studies as a basis for developing the DSM. The APA made its decision to remove homosexuality from the list of mental illnesses in the context of strong evidence that was supportive of the fact that homosexuality was not uncommon and that homosexuals did not have mental illnesses due to homosexuality itself. Researchers like Kinsey, Clellan Ford and Frank Beach, and Evelyn Hooker were among several researchers that contributed significantly to this field and helped change people’s view of homosexuality. (13)

Forty years have passed since the APA’s decision to remove homosexuality from the list of mental illnesses, and the DSM has been revised several times since then. These four decades would have given anyone plenty of time to prove that homosexuality in itself is a disorder; however, this has not happened.

SOCE Are Not Effective:

Since 2000, the APA’s position urging mental health care providers against SOCE has been clear. In addition, over the last decade, several other major professional organizations released statements regarding SOCE. To name a few, the American Psychological Association (apa), the American Academy of Child and Adolescent Psychiatry (AACAP), and the American Academy of Pediatrics (AAP) emphasized, in statements they issued on this issue, the lack of evidence proving that this kind of therapy can actually change one’s sexual orientation (13, 14, 15).

The apa formed a task force that reviewed the literature related to SOCE. The task force reviewed 83 studies published between 1960 and 2007. They found major methodological issues with these studies. Some of these issues included failure to control for confounding factors, lack of control subjects, and being qualitative. They concluded that “Given the limited amount of methodologically sound research, claims that recent SOCE is effective are not supported.” (13)

Even in his apology to the gay community, Robert Spitzer stated: “I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some “highly motivated” individuals.” (3)

SOCE Can Be Harmful

As it is, research has consistently shown that Lesbian, Gay, Bisexual, and Transgender (LGBT) people are at higher risk of developing psychiatric conditions such as depression, anxiety, and substance abuse. It’s widely believed that these disorders are not due to the LGBT people’s sexual orientation itself but rather due to the pressures that LGBT people face in their homes and communities. (16) It would be considered unethical to promote practices that can bring further harm to LGBT people.

Unfortunately, SOCE continues to be practiced in many parts of the world, causing further harm to this population. Evidence of the harm that such practices can cause has been well documented. In 2002, Ariel Shidlo and Michael Schroeder published a landmark study where they interviewed 202 individuals who had undergone SOCE. Many of these individuals reported that they experienced psychological, social and interpersonal, as well as spiritual harm, as a result of this type of therapy. (17) More recently, in their review of the literature related to SOCE, the APA task force found evidence that SOCE resulted in harm. “These negative side effects included loss of sexual feeling, depression, suicidality, and anxiety”. (13)

Even prior to these studies, there was enough evidence of the harm that can result from SOCE, that the APA recommended that “ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the medical dictum to First, do no harm” (18)

Several other professional and well respected organizations concur with the APA’s position. AACAP and AAP emphasize that SOCE can be harmful to individuals undergoing this kind of therapy. (14, 15). According to the statement by AAP, individuals undergoing SOCE can experience feelings of anxiety and guilt as a result of it. (15)

In May 2012, PAHO released a statement that echoed the statements mentioned above and affirmed that reparative or conversion therapies “represent a severe threat to the health and human rights of the affected persons.” Furthermore, PAHO states that “Repression of sexual orientation has been associated with feelings of guilt and shame, depression, anxiety, and even suicide” (12)

Conclusion:

Given the controversy associated with SOCE currently, the authors felt it important to emphasize the facts that have been clearly established, prior to expressing an opinion or making any recommendations.

Here are the basic facts:

Homosexuality is not a mental illness and, therefore, requires no treatment.

SOCE lack sound scientific evidence supporting its effectiveness.

SOCE can be harmful.

PAHO calls, in its 2012 statements, on professional associations to “disseminate documents and resolutions by national and international institutions and agencies that call for the de-psychopathologization of sexual diversity and the prevention of interventions aimed at changing sexual orientation.” (12)

In this country, the APA has taken many positive steps in this direction. However, given that the United States allows for individual states to regulate licensure, professions and practices, we urge the IPS and IPS members to take more proactive measures in support of evidence-based practices, in the state of Illinois against SOCE and its harmful effects. As physicians, it is our duty to advocate for our patients, and first, do no harm, which is where it starts.